An Adaptive User Interface Framework for eHealth Services based on UIML

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23rd Bled eConference
Implications for the Individual, Enterprises and Society
June 20 - 23, 2010; Bled, Slovenia

An Adaptive User Interface Framework for
eHealth Services based on UIML
Joël Vogt
Department of Informatics, University of Fribourg, Switzerland
Andreas Meier
Department of Informatics, University of Fribourg, Switzerland

New sensory technologies and smaller, more capable mobile devices open opportunities
for pervasive computing in the healthcare sector. Patients as well as medical profes-
sionals are, from a information and communication technology (ICT) point of view, bet-
ter equipped than ever before. Despite this, many hospitals and other healthcare service
providers have yet to exploit the potential unleashed by these technologies. In this pa-
per, we present a framework for adaptive user interfaces for home care and smart hos-
pital services. The framework uses the current context to provide healthcare profes-
sionals or patients with simpler, more efficient user interfaces. In a home care environ-
ment, user interface adaption is needed to tailor user interfaces to patients needs and
impairments. In a smart hospital, user interface adaption considers medical profes-
sionals’ preferences and priorities. In addition, by using context to make input sugges-
tions simplifies the input and limits the scope for errors. Our frameworks uses a model-
based approach and includes the current context in the interface generation process.
Keywords: Human-Computer Interaction, eHealth, Adaptive User Interfaces, UIML

1 Motivation
The increasing complexity of the healthcare sector has created the need to improve effi-
ciency, quality and security of healthcare services while maintaining cost effectiveness.
The Economist Newspaper (2009) explains that the ICT investments are helping to
drive costs down in the healthcare sector. The widespread dissemination of ICT enables
more portable healthcare services that are customized to the individuals’ need. For ex-
ample, patients’ physiological parameters can be monitored remotely and the data can
be sent to a medical specialist, thus avoiding expensive checkups and allowing the pa-
tients to lead a normal life. The almost instant availability of this data allows medical
Joël Vogt, Andreas Meier


professionals to react immediately, instead of having to wait for the next medical
checkup (The Economist Newspaper Limited, 2009). The dynamic environment in
which healthcare processes execute, offers new challenges and opportunities for the
ICT. The User Interface (UI) is the direct point of interaction between the medical pro-
fessional or the patient and the application. It is thus of utmost importance that the user
can easily execute his intention at the UI and interpret the results displayed.
The prevalence of smartphones, such as the Apple iPhone or smartphones running
Google Android that have the versatility of computers as well as the reemergence of
tablet PCs, offer new, flexible ways to interact with information. Additionally, wireless
sensors to track patients physiological parameters and in- and outdoor location tracking
systems (e.g. GPS and Ubisense
) have open new possibilites to improve healthcare, for
patients as well as for medical professionals.
Therefore, interfaces that are developed for a single device type may no longer be ade-
quate. For example, a workflow management system to support administrative work-
flows in a hospital will be used by different actors (e.g. physicians, nurses) and the same
actor may use the application on multiple devices. Sainfort et al., (2007) emphasize the
need for research in the development of adequate UI in the healthcare domain. They
predict that “[. . . ] interfaces will automatically adapt themselves to the user [. . . ], task,
dialogue, environment and input/output modes in order to maximize the effectiveness of
the HCI” (Sainfort et al., 2007, p.675).
Model-based UIs offer a promising approach to automated UI generation in a multi-
device environment. UI designers develop the models upon which the UIs are based.
During run-time, the UI is generated by applying a set of transformation algorithms to
different types of models.
In this research, we develop a framework for mobile and adaptive user interfaces for the
healthcare domain. The framework is developed as part of the Location and Context
Aware eHealth Infrastructure (LoCa) project (Fröhlich et al., 2009). The LoCa frame-
work consists of two main layers: The adaptive Workflow Management System
(WFMS) layer (developed with the OSIRIS Next framework (Möller, 2009) and Hu-
man-Computer Interaction (HCI) layer. We use of he shelf technologies. The LoCa
framework runs on Google Android, an open source Operating System (OS) available
on a number of mobile devices. The HCI framework uses a set of XML languages for
the models and artifacts. The adaptive UI is based on UIML, a highly flexible markup
language for the design of UIs, which is an OASIS standard and supported by several
organizations in the private and academic sector.
Section 2 presents a simple use case to illustrate the use of the framework. Section 3
elaborates on the conceptual models, followed by a description of the HCI architecture
in section 4. In section 5 related research is discussed. This paper closes with an outlook
on future work in section 6.
2 Use Case: Patient Visit
To illustrate the application of the HCI framework, consider the following use case in a
smart hospital: Each medical employee is equipped with a Android smartphone with
touchscreen display. Additionally, they have access to workstations and may also use


An Adaptive User Interface Framework for eHealth Services based on UIML


tablet PCs. The smart hospital is equipped with the indoor location tracking system Ubi-
sense. Each room has an entertainment multimedia set for each patient, to watch TV,
access the internet or listen to music. Additionally, a Hospital Information System
stores the patient record of every patient. The patient record contains information in-
cluding the patient’s personal information (e.g. name, date of birth), current room, ad-
mission date and medical history. Patients have their heart rate and blood oxygen satu-
ration constantly monitored. These measuring devices are registered to a specific user
and have a bluetooth interface. In addition, some of the devices for measuring additional
physiological parameters (e.g. glucose meter) that are carried by a nurse are also
equipped with a Bluetooth interface.
The patient Mrs. Thrace has injured her knee. She is scheduled for a knee surgery in the
late afternoon. The orthopedist visits Mrs. Thrace after breakfast to discuss the surgery.
He switches on his smartphone that runs the LoCa framework. The LoCa system looks
up his patients that are in his proximity and present a list of patients to choose from, in
this case Mrs. Thrace. The orthopedist selects Mrs. Thrace’s electronic health record.
The system knows, based on the orthopedist’s user profile, his preferences and, based
on the device profile of his smart phone, the device attributes, including the size of the
screen. The system displays a scaled down X-Ray image of Mrs. Thrace’s knee and ad-
ditional textual information. The LoCa system recognizes Mrs. Thrace’s multimedia set
as a possible host to run the process. The orthopedist selects the multimedia set to which
the curent task is seamlessly migrated. The LoCa system adapts the display to the new
device constraints and displays the image in high resolution. Afterwards, at the end of
the consultation, the orthopedist migrates the task back to his smartphone and takes a
few notes. He then returns to his office. To finish his report, he migrates the task to his
workstation, which is more suited for larger text inputs.
3 User Interface Models
A common approach in the development of adaptive interfaces is to use a set of models
(e.g. for domain and context of use) to generate and further refine a user interface arti-
fact or artifacts until the final user interface is adapted to best match the user’s need,
given the constraints set by the context in which the user operates (Jaquero et al., 2009).
The adaption process is shown in figure 2.
The Cameleon reference framework proposes four different abstraction layers for adap-
tive interfaces for a step by step generation of a user interface. The user interface pre-
sented to the user is referred to as the Final User Interface (FUI). The FUI is rendered
by the UI toolkit of the given platform, for example GTK+ or Java Swing. The FUI is
derived from a Concrete User Interface (CUI). This model is basically the same as the
FUI, but independent of the toolkit description language. The CUI is generated from the
Abstract User Interface (AUI). The AUI describes the interface independent of interac-
tion modalities and devices. The AUI is derived from a domain model (the task and
concepts model combined) (Calvary et al., 2003). The following section discusses the
models applied in the interface adaption process (i.e. task model, concepts model, con-
text model and UI model) followed by a description of the automated adaption process.
3.1 Task Model
Task analysis captures the way a human plans to perform a given task. Humans natu-
rally tend to decompose problems into subproblems. Thus a common way to structure
Joël Vogt, Andreas Meier


task models is a hierarchy. A number of tasks models have been developed. One of the
more frequently used notation in the UI development is the ConcurTaskTrees (CTT) by
Paternò et al., (2000). CTT has four types of tasks: system tasks that are conducted by
the system alone, user tasks that are only allocated to a user, interaction tasks that are
conducted by the user with the system and abstract tasks. Tasks are further divided in
subtasks. Tasks are connected to their siblings through temporal operators. CTT also
supports cooperative tasks that imply the action of more than one user. Van den Bergh
and Coninx (2004) have extended the CTT notation to support dynamic context infor-
mation. With this context-aware extension, this notation permits to model complex in-
teraction and handle unexpected events that occur in a dynamic healthcare environment.
For example, if a physician, who is currently visiting a patient, is required in the emer-
gency room, the current activity can be suspended and the more urgent task suggested,
if approved by the user, and loaded.
3.2 Concepts Model
The concepts model describes the objects with which the user interacts through tasks
(Van den Bergh and Coninx, 2004b). Various healthcare related vocabularies for type
level semantics and instance level semantics (e.g. patient care, index, cataloging bio-
medical literature) are available. Type level semantics describe the structure of informa-
tion objects while instance level semantics structure the content of information objects
(Beyer et al., 2004). For the prototype to validate the use case presented in section 4, we
chose Clinical Document Architecture – Confoederatio Helvetica (CDA-CH) to de-
scribe type level semantics and ICD-10 for the instance level semantics. CDA-CH was
favored for this research due to the fact that it has found wide acceptance in Switzerland
and is easy to test in hospitals.
CDA-CH is an adaption of the XML based on Health Level 7 (HL7) Clinical Document
Architecture (CDA) (release 2) healthcare documentation standard for Switzerland. A
CDA-CH object consists of a header and a body. The body may contain a number of
objects, including multimedia objects and references to external objects (HL7 Benutzer-
gruppe Schweiz, 2009).
Figure 2. Models and artifacts in the adaption process
An Adaptive User Interface Framework for eHealth Services based on UIML


ICD-10 is a standard developed by the World Health Organisation (World Health Or-
ganization, 2007) which is used by many healthcare related institutes. We use this on-
tology to use a uniform vocabulary for the description of the patient’s diseases.
3.3 Context Model
The context model stores the relevant information that is collected or managed by the
system (Jaquero et al., 2009). Dey (2001) declares “Context is any information that can
be used to characterize the situation of an entity. An entity is a person, place, or object
that is considered relevant to the interaction between a user and an application, includ-
ing the user and applications themselves”.

Figure 3. LoCa Context Model (obtained from Fröhlich et al., 2009)

The LoCa project provides an upper level context model (Fröhlich et al., 2009), shown
in figure 3. A subject is any entity in the environment, such as a person, a device or an
information object. In the LoCa model, subject can be further subdivided into two types:
data generators which produce information about the current context and the context
information themselves. A data generator can be a human (e.g. the patient who manu-
ally enters his weight), a hardware device (e.g. position devices or sensors) or a soft-
ware process (e.g. monitoring daemon). Data generators can operate in a specific mode.
The fact that context information are themselves subjects permits to annotate context
data with further contextual information. For example, with this model, the location and
time when a given measurement was taken, can be captured. The measurement is con-
text data and at the same time the subject that is being further described with the date
and a location. Context objects can be aggregated. The LoCa context model can further
be refined by including domain specific models.
According to the Cameleon reference framework, context can be subdivided in three
categories: user, device and environment (Calvary et al., 2003).
∙ The user model contains information about the current user. Generally speaking
“the user’s knowledge, interests, goals, background, and individual traits.”
Joël Vogt, Andreas Meier


(Brusilovsky and Millán, 2007). We use a subset of the HL7 Reference
Information Model to users, namely the “Person” class and the “Employee” and
“Patient” class (HL7 Benutzergruppe Schweiz, 2009).
∙ The device model describes physical device and software attributes of the
platform the framework is running on. Attributes include the CPU speed, screen
size, sound capability, OS, etc. A standard for device models is the User Agent
Profile Specification (Wireless Application Protocol Forum, Ltd., 2001).
∙ The environment model contains information about the environment in which
the process executes (Jaquero et al., 2009).
3.4 Abstract User Interface Model
A generic vocabulary, a vocabulary that is platform and modality independent, will be
developed for this framework containing abstractions suited for abstract interface ob-
jects in e-health. Using abstract vocabularies permits to support a wide variety of de-
vices (Luyten et al., 2005; Ali, 2004). These classes are then mapped to the CUI for the
UI toolkit that is used. We use two types: composite objects that contain other abstract
user interface objects and atomic abstract user interface objects. Atomic abstract user
interface objects are the leafs in a abstract user interface tree. Abstract composite user
interface objects can either be structured when the order of the child objects matters or
unstructured, if the order is arbitrary.
The abstract user interface model has to be extended relative to the concepts model.
Thus in the context of this paper, the AUI model will be extended to include CDA-CH
ontology objects (see section 3.2).
3.5 Concrete User Interface Model
The CUI model is platform dependent. It specifies the widget types and makes assump-
tions about the look and feel of the user interface. This model is then mapped to the
FUI, in this case the Android UI. A UIML renderer for Android is being developed as a
Bachelor thesis at the EDM, Hasselt University in Belgium.

3.6 Final User Interface: Android
Android provides its own UI toolkit. The abstract classes are “View” and “View
Group”. A View Group object can contain several View objects. View Group is a sub
class of View. New widgets can be added by third party developers. Android interfaces
can either be defined in Java or in a XML vocabulary. Android separates the user inter-
face in structure, style and content. View objects are arranged in a tree structure. The
layout of view objects is defined with layout View objects. Layout views are subclasses
of View group. View objects can be parametrized in a uniform manner with styles and
themes (Google Inc., 2010).
4 The HCI Architecture
The HCI layer is decoupled from the workflow engine (see figure 4), thus it could easily
be used with another workflow engine to add HCI process steps. The integration with
the workflow engine is through message passing: whenever the workflow needs to exe-

An Adaptive User Interface Framework for eHealth Services based on UIML


cute a process step that requires human-computer interaction, it sends a message to the
HCI module with the unique id of the task model it has to perform. The HCI module
loads the requested task model and launches the task. The workflow engine waits for the
HCI module to complete the step and resumes operations.

Figure 4. Architecture of the HCI Module
Separating the business process modeling and workflow execution from the human-
computer interaction has several advantages:
∙ Reducing complexity: The business process description is not cluttered with
atomic steps that the user has to perform, but are too fine grained for the process
description. Modeling the user interaction separately reduces the complexity of
the process model.
∙ Separation of concerns: A process engineer might not have the knowledge
required for user interface design nor might he be interested in such details.
With this approach, the process engineer and the user interface designer can
focus on their area of expertise.
∙ Increased flexibility: The task model can be adapted without changing the
overall process. The workflow engine only specifies the required input.
The architecture of the software consists of three tiers: the task manager, the interface
manager and the presentation tier (see figure 4). Each layer receives information from
the n−1th layer and provides information to the n + 1t h layer. Furthermore, each layer
communicates with the Context Manager (CM). The CM is the single source of contex-
tual information for the layers. A layer however does not interact directly with the CM.
Instead, each layer uses a plugin that offers a uniform interface to the CM. This addi-
tional abstraction permits to replace the CM, without affecting the transformation layers
in the framework.
The interface tier manages the user interface artifacts. When the task manager first
pushes the task model, it compiles a UIML AUI based on the abstract vocabulary that
was customized for the domain in which the process performs (in this case the patient
visit). The creation of this UIML artifact is performed once every time the workflow
engine requests a specific task model to be executed for a given workflow instance.
During the execution of the HCI process step, the main purpose of this artifact is to
Joël Vogt, Andreas Meier


manage the structure and state of the interface (i.e. UI objects composition) and to apply
changes to the interface if changes in the context demand it.
The interface tier maps the AUI into the CUI and propagates changes of the structure in
the AUI to the CUI. From the CUI, the interface manager updates the FUI, which is
managed by the platform dependent toolkit. The FUI is only presents an interface to the
user and captures the user’s input, which it directly passes to the context manager. The
dialog flow is controlled by the interface tier.
4.1 User Interface Structure
A number of languages for abstract dialogue modeling are available. Popular examples
are UsiXML and UIML.
∙ UsiXML has the advantages that it follows the abstractions layer of the
Cameleon reference framework and offers a comprehensive toolkit. However,
UsiXML cannot be extended without altering the language (Meskens et al.,
∙ UIML is a markup language to create UI vocabularies. These are either mapped
to concrete representations or to other UIML vocabularies.
UIML will be chosen for several reasons. First, UIML provides a clear separation of
content, structure, behavior and style. UIML is modality-independent. Furthermore, it is
meta language, thus does impose any mental models or dictate specific widget types.
New vocabulary can be build without changing the language. Additionally, UIML uses
XML, this facilitates the integration with other XML technologies. Finally, UIML is an
open standard that is being further developed by a number of academic and private or-
ganisations (the current version under development is 4.0 (OASIS User Interface
Markup Language (UIML) TC ,2009)).
UIML has been criticized for being too tightly coupled to the underlying modality for
which a given vocabulary was designed (de Melo et al., 2009). This issue is however
been addressed by improvements of the UIML standard and combination with other
XML technologies (Helms et al., 2009).
UIML is based on the Meta-Interface Model (MIM). The MIM is divided in three com-
ponents (Phanouriou, 2000):
∙ Presentation: The presentation component describes the interface vocabulary. It
contains the classes that can be used in an interface, their properties and event
handling. The presentation component maps the vocabulary classes to either
concrete widgets or another UIML vocabulary.
∙ Logic: The logic components abstract the concrete Application Programming
Interface that the interface component uses to communicate with the underlying
application layer. The methods defined in this component are used by the
interface component.
∙ Interface: The interface is described in an abstract way by separating the
structure in different concerns. The elements that are used in the interface are
described in the peers (the presentation and logic component).
An Adaptive User Interface Framework for eHealth Services based on UIML


4.2 Adaption Process
This section describes the adaption process for the user interface. The goal of this
framework is to automatically optimize the user interface during run time to best meet
the actors needs. To achieve this, at every stage transformation heuristics are applied to
construct the next interface artifact until the FUI is presented to the user. The transfor-
mation rules are categorized in different types which are applied at different stages of
the transformation process. Transformation rules are created by human experts and cod-
ify best practice patterns for predefined situations as well as fall back rules, as suggested
by (de Melo et al., 2009). Rules at different stages can be developed independently of
each other. At each stage, different contextual information are included. The transfor-
mation is based on the Cameleon framework. Figure 2 has given a high level overview
of the models and artifacts involved in the UI generation. Our approach veers from the
Cameleon framework by consulting the context at every step of the UI transformation.
For example, the device model is already consulted to create the AUI, since different
device types differ in screen size. Furthermore, the models are adapted during run-time
and the context is applied to assist the user to articulate his input by offering a selection
of input choices.
The task and concepts model form the basis for the user interface. The transformation
rules generate an UIML abstract user interface based on the task and concepts model.
This transformation step is already context dependent. The AUI is generated based on
the device model (screen size of the device), user preferences and impairments and the
amount of input information that can be presented based on the current context. The
system then updates the AUI to present input value selections based on the current con-
text. For example, if the nurse needs to enter the patient’s blood sugar level and the sys-
tem finds a glucose meter that is registered for the patient the nurse is currently treating,
a abstract user interface object containing the value provided by the glucose meter will
be added to the AUI. If the framework cannot find suitable context information to assist
the user, the human data generator (i.e. the user himself) will have to provide the input.
The framework adds an abstract input interface object.
Next, the AUI is mapped to the CUI. The device model is used to select the CUI UIML
vocabulary that corresponds to the installed UI toolkit and to make device dependent
adaptions (e.g. based on the screen size). The user model is used to adapt the layout
handling to user’s preferences for a customized arrangement of the user interface. Once
the CUI is correctly parametrized, the UIML file is transformed to the FUI and pre-
sented to the user.
5 Discussion of Related Work
We see it as important to use context-aware adaption for user interfaces in the health-
care domain. The inclusion of the user and device model is required to adapt a user in-
terface to varying needs of medical professionals and, in a home care scenario, to the
patient’s preferences and impairments. In addition, to use the context during run-time to
help the user with the input selection, may simply and accelerate the interaction and re-
duce errors. Our approach fulfills these requirements. Moreover, by using UIML and
clearly distinguishing between the UI architecture and the WFMS engine, the HCI
framework presented is technology independent and therefore more portable.
Joël Vogt, Andreas Meier


A number of adaptive user interfaces and mobile healthcare applications have been de-
veloped in recent years:
∙ De Melo et al., (2009) propose an adaptive user architecture for board computers
in cars, which allows to integrate different device types (e.g. smart phones, mp3
players) with the in-car environment. The goal is to access these devices through
the uniform interface of an in-car system. Device only provide a task model and
abstract user interface description. Their framework leans on the Cameleon
framework. They describe the task model and in the same step the abstract user
interface model, in UML. Transformation rules are used to map the abstract
user interface to different modalities and optimise the final user interfaces. The
user interfaces are described in their own OWL language. The system supports
switching modalities during run-time and adding new devices. Unlike our
approach, the abstract user interface is not derived from the task model. This, as
the authors explain, makes transformation easier. However, the abstract user
interface cannot be compiled in function of the current context. Additionally,
user preferences and environmental information are not considered in the
∙ Martinez-Ruiz et al., (2008) developed a framework for adaptive user interfaces
on mobile devices. They use the web pages, which need to be displayed
correctly on a variety of devices, to make their case. Their approach uses
UsiXML, CTT and the Cameleon framework. The transformation based on
several iterations. They use the device model and the CTT to compile an abstract
user interface suitable for the display. This is further refined for the platform
type. Their approach differs from the framework presented in this paper in the
UI language used and in the models consulted for the adaption. Our approach
also includes the user model in the transformation and the models are adapted
during run-time to the current context, for example to make input suggestions to
the user.
∙ Portmann et al., (2010) are developing a smart environment, in which the user
navigates by using a mobile device. The device receives context information
from available sensors. In their approach, they use a fuzzy expert system to
decide which information is relevant for the user based on the user model (his
profile and location). Their adaption focuses on the content displayed in a
dialog. The goal is to provide the data that meets the user’s current profile and
location. They do not, however, follow a clear separation of layers in their
adaption framework. This makes support for different devices and output
modalities is difficult. Nor does their system use the current context to aid the
user with input selection.
The use of mobile devices in the healthcare sector have also been explored in a number
of projects:
∙ Zao et al., (2008) developed HealthPal, a personalized smart phone to assist
elderly people. Part of their system is a smart phone, optimized to ease
interaction of the device for senior citzen. Senior citizen can use Health Pal to
communicate with healthcare providers, receive medical instructions, manage
their diet and measure their physiological parameters, which are sent to their
healthcare provider.. The adaption of the user interface tries to lower the
An Adaptive User Interface Framework for eHealth Services based on UIML


complexity for the user. The adaption is based on the user model and the
environment. It displays the menu items based on the user’s activities focus and
further arranged based on their frequency of use.HealthPal also unburdens the
user by using the context. It can connect to the user’s wearable biosensors and
read the measured physiological parameters.
∙ The system presented by Zao et al. is is highly specialized for support of senior
citizens. The framework is not designed with the possibility to be easily ported
to different domains.
∙ Ardissono et al., (2008) developed a context-aware Service-Oriented
Architecture framework for adaptive web-based applications that can adapt the
UI and application logic based on the user’s context. To test their approach, they
implemented a e-health application to help coordinate activities required to
monitor patients with heart diseases. The user interface and the workflow
systems are coupled. The user interface is created based on a task description.
In a first step, the system selects XSL Transformation artifacts developed for the
user’s current device. The user interface objects are grouped to fit the device
screen and in function of the user’s interests. The pages are then rendered from
that representation for the target user. The system differs from our approach in
several ways. Their system is web based, we do not predefine the final format.
Furthermore, their framework differs in a sense that it does not clearly separate
the abstract user interface and concrete user interface and does permit a more
fine grained adaption and, while they too chose a modular approach, they do not
emphasize the separation of workflow engine and user interface component.
6 Conclusion and Outlook
This paper presented an adaptive HCI framework for adaptive WFMS in the healthcare
environment. Our goal is to facilitate the medical professional’s daily work. By using
contextual information, the UI is rendered in real-time to present the user with a consis-
tent and relevant interface. The next steps of the ongoing research project is the devel-
opment of a prototype for Google Android as a proof of concept. The prototype uses the
UIML engine for Android, developed at the EDM. The prototype will be evaluated with
healthcare professionals as part of the LoCa project.

We express our gratitude to Nadine Fröhlich, University of Basel, Dr. Anthony Dyson,
Chief Information Officer at Medgate AG, Dr. med. Serge Reichlin, Head Health Inno-
vation at Siemens Schweiz AG and Professor Dr. Thomas Strahm, University of Berne
for their invaluable input.
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